Financial Discipline Award Registration Form Before submitting your application, you MUST have a 529 College account before or by the start of the program date. NJBEST is an option, but speak to your local banker for advice. 1a. Teen Name (required) 1b. Teen: Are you a returning participant (required)? Yes-enter the person name you referred below (1c)No-enter the person name who referred you below (1d) 1c. Person Name You Referred, if question 1b is "Yes" 1d. Person Name Who Referred You, if question 1b is "No" 2. Teen Address (required) 3a. Teen Residence - City / Municipality (required) OrangeWest OrangeOther, Specify below 3b. If you select "Other" from the list above, specify City / Municipality below 4. Teen: do you have a cell phone (required)? Yes-enter cell phone belowNo 5. If "Yes" to question 4, enter cell phone number below 6. If "No" to question 4, enter guardian's cell phone number below 7. Teen: do you have an email (required)? Yes-enter email belowNo 8. If "Yes" to question 6, enter email address below 9. Teen: School attending (required) Orange, NJ - Middle SchoolOrange, NJ - Preparatory SchoolOrange, NJ - High school - FreshmanOrange, NJ - High school - SophomoreOrange, NJ - High school - JuniorWest Orange, NJ - Edison Middle SchoolWest Orange, NJ - Roosevelt Middle SchoolWest Orange, NJ - Liberty Middle SchoolWest Orange, NJ - High SchoolWest Orange, NJ - Seton Hall Preparatory SchoolOther school - List the name below in item 9a. 9a. If you select "Other" from the list above, please enter school name below 9b. What is your principal's name? 9c. What's your principal's email? 9d. What's your principal's phone number? 10. If you attend a church, list church name and address below 11. Teen Grade (required)?2nd3rd4th5th6th7th8th9th10th (Sophomore year) 12. Teen: Do you get an allowance (required)? YesNo 13. Teen: If you receive an allowance, do you earn it (e.g., you are assigned task or conditions). Select "N/A" option below, if not applicable (required)? YesNo - I get it with no conditionsN/A - I do not get an allowance 14. If you get an allowance and earn it, specify how you earn it or conditions list all. If you do not get an allowance, how do you think you could earn it 15. Teen what are you seeking to gain / learn from participating in the FDA Program (required)? 16. Upload copy of school Id (file must be 10 MB or less) - required 17a. What is the name of your 529 account holder? 17b. What is the account number for your 529 account? [ 17c. What is the mailing address for your 529 account (include city and zip code as well)? [ 18a. Teen, by checking the certification box below, I certify that all information provided is accurate and I intend to participate in the 3 workshops to improve and develop great financial discipline skills. Should I be awarded a cash prize (1st, 2nd, or 3rd) I agree to open and/or add 50% of the proceeds to the 529 College account and I acknowledge if I am not present nor a representative at the Award Ceremony the next candidate in line will win my cash award (required). Teen Certification Check Box 1 18b. I further certify, should I miss a workshop and not make up the exercises, I will be disqualified from the program. Because, I will not have personally understand the expectations from me as personally heard at the sessions. I do understand that I can return the following year (required). Teen Certification Check Box 2 BE SURE TO ANSWER ALL QUESTIONS NOT TO DELAY THE REGISTRATION PROCESS 19a. Parent or Legal Guardian Name (required) 19b. Parent/Legal Guardian Address (required) 19c. Parent or Legal Guardian Residence - City / Municipality (required) OrangeWest OrangeNewarkSouth OrangeEast OrangeOther, list below 19d. If you select "Other" for question 17c, List City / Municipality below 20. Parent or Legal Guardian Phone Number (required) 21. Parent or Legal Guardian Email (required) 22. Which expense lane do you wish your teen to reduce usage check all that applies (program recommends Electric, Gas, Water, FoodCoupon and Other) - required ElectricGasWaterFoodCouponingOther 23. Parent / Guardian - Certify box below, I certify that all information provided is accurate and I intend to participate in Workshop 1 jointly with teen to improve and develop great financial discipline skills. Parent and Legal guardian also acknowledges that failure to be present at the award ceremony or send a represent will result in cash award to the next winner (required). Parent or Legal Guardian Certification Checkbox 24. What adaptation do you wish your teen to sustain after the program (required) 25. How did you hear about CORESSWC'S FDA Program?